Sunday, February 24, 2013

Review of Normal Oral Motor & Swallowing Development by Imaginart

An area in our Speech-Language Pathology field that I am just chomping at the bit to learn more about is pediatric feeding and swallowing. So when we were cleaning out our "speech closet" the other day and I found the VHS...yes a VHS :-) "Normal Oral Motor & Swallowing Development - Birth to 36 Months" by Imaginart I was so excited!

First, why start at normal? A very wise professor of mine once said "if you don't understand normal then you will never know what to do with abnormal." So so true! Second, I am very comfortable with adult anatomy but the anatomy is so different with the pediatric population!

For lack of a better term everything is so neighboring!

As you can see major anatomical differences include:
  • The oral cavity is smaller than in the adult
  • The tongue fills the mouth and rests more anteriorly (at the front of the mouth)
  • The soft palate, tongue and epiglottis approximate (touch)
  • The lower jaw (mandible) is small and pulled back
  • Anterior movement of the pharyngeal wall is much greater
  • The larynx is higher and pharynx shorter causing less hyo-laryngeal excursion (elevation and depression of the larynx and hyoid bone thus leading to epiglottic inversion - one of the four system in place to protect the airway) in infants.
  • Sucking pads exist.

I have been told by one of my fellow SLP's that has experience within pediatric feeding and swallowing that when you are learning about pediatric feeding and swallowing the best practice is real life practice. Now when you do not have any babies (like me) this makes learning in my natural environment difficult. One of the pro's of this movie is that it showed (quickly) various children starting at birth and moving by approximately 2-3 months at a time up to 36 months of age, eating and drinking various items. I felt that this was very nice with my lack of real world experience. With the video you could see obvious changes in oral-motor control for feeding and swallowing as the child aged.

One of the con's of this movie is that it was unbelievably quick! So quick that I felt that it was impossible to take notes along with the movie. Luckily they included the script of the movie. So I took notes before I watched. This was actually a good thing because then I could really attend to the movements of feeding and swallowing with each child, as opposed to rushing to take notes.

Below are my notes that I took if you are interested in more of a break down of oral-motor development.

Four important factors are common to all age groups:

1.Rhythmicity - the child's ability to produce rhythmic movement patterns.
        * First seen in infants when they suck - allowing for coordination between breathing, sucking, and swallowing.
        * Rhythmicity continues through each stage of development. 

2. Stability - the child's ability to hold the body steady.
        * Stability is first provided by physical characteristics and motor patterns that are present at birth. 
        * One of the earliest forms of stability is the pads of fat (sucking pads) inside the infant's cheeks. This compensates for an early lack of voluntary motor skills. The sucking pads help hold the nipple in a stable position. 
        * Sucking pads are predominant during the first three months and disappear as the child gets older. 

3. Physiological Flexion - aka the fetal position.
        * Provides stability for sucking.
        * Physiological Flexion causes the entire body to flex or bend into a natural stable position. In this position the infant only needs to open and close the mouth to achieve stability for sucking.

4. Separation of Movement - the child's ability to move one part of the body without moving other parts. (I have also heard this called dissociation). 
        *Separation of movement appears as the child's stability increases, allowing mature chewing patterns to develop. 
                -Example: when the child is able to move the tongue without moving the jaw at the same time.
        * Separation of movement is important not only for swallowing but also in speech development.

How do oral-motor skills apply to feeding as a child develops during the first three years?

0-3 Months
1. Primitive Reflexes 
        a. Rooting - causes the infant's head to turn toward a touch on the lip or cheek
        *This is important because it orients the child to the nipple for food

        b. Mouth-opening - as the baby turns the head the "mouth-opening" reflex is also triggered when either the lip or the cheek is touched. 
        *The touch to the lip or the cheek will stimulate the mouth to open wide thus so it is ready to accept the nipple. 

        c. Phasic Bite - causes the mouth to open and close when the gums at the sides of the mouth are touched. The phasic bite is an easy up-and-down movement when the finger is placed on the gum ridge. 
         *This prepares the mouth for true chewing.

        d. Sucking - moving the finger to the center of the tongue will trigger a sucking reflex.
        *Sucking begins as the lips move forward to surround the nipple. 
*Interesting - the infant does not recognize the bottle by sight (does not follow it visually) because cognitive and visual development is immature. Though the infant can easily recognize the nipple by touch.

*Additional Information: The infants tongue will be flat with the sides thinned and cupped up thus making a channel for moving the liquid back in the mouth for swallowing (the infant must be able to make this cup to be able to pump liquid from the nipple). When the bottle is removed there should be a strong suction inside the mouth and the lips will stay in a forward position as the nipple is returned to the mouth.

*Core Points to take away: Knowledge of primitive reflexes, the tongue is flat and cupped, the swallow is triggered by the suck, and the jaw, tongue & lips do not move independently.

4-6 Months
*The development of voluntary control is called integrating the reflex (overriding the primitive reflexes as the nervous system matures).
        -Rooting reflex integrates by 5 months.

*An efficient sucking pattern is created.

*When a spoon is presented the tongue moves in and out - in a good suck-swallow pattern. This pattern moves the bolus to the back of the mouth for swallowing. Tongue protrusion is typical but should be easy and well controlled, the tongue protrusion is strong due to the child having difficulty moving the bolus to the back of the mouth. If it is forceful this may be a sign of neuromotor dysfunction. Moderate loss of food is typical.

*Interesting - at this age the child has no difficulty recognizing the bottle by sight and will use flexion to move toward the bottle. 

*Core Points to Take Away: infantile reflexes become integrated, there is difficulty transferring semi-solids to the pharyngeal cavity, a suck-swallow pattern is developing/should be developed, loss of semi-solid food is normal, jaw, tongue & lips do not move independently, and easy tongue protrusion occurs when swallowing.

7-9 Months
*Finger feeding begins with most 7-9 month-olds.
*The child can hold the jaw in a closed position - the child can break a cookie off in their mouth though a controlled bite will not develop until approximately 9 months (most children up until nine months lack the strength and stability for precise jaw movements).
*The tongue can move the bolus from side to center and center to side in the mouth but not across midline. 
*The child will use their lips and cheeks to control much of the bolus.
*The suck-swallow and breathing patterns are coordinated; the child should now swallow independently of the preceding suck and should not be losing liquid when using a bottle. If transitioning to a cup the infant will still use a suck pattern.
*Sensory awareness is heightened and children have more control of their hands and mouths.

*Core Points to Take Away: lips show lateral closure, closing tightly at the corners, jaw movements separate from tongue and lip activity, lower lip pulls in to remove food, upper lip cleans spoon, unstable jaw movements with cup, a coordinated suck-swallow-breath pattern is evident, the bolus can now be transferred from side to center of the tongue and center to the side. 

10-12 Months
*Bite is now controlled; jaw opening and closure are well graded.
*Lip closure occurs when swallowing 
*Lips and cheeks are used to draw in the food and there is an active use of the cheeks to control the bolus and move it around in the mouth.
*Less up-and-down jaw movement as the child drinks, showing the ability to coordinate swallowing with little spillage.
*Liquids are now taken in longer sequences.

*Core Points to Take Away: Decrease in up-and-down jaw movements when drinking from a cup, upper incisors are used to clean lower lip, lip closure while swallowing liquids and solids is common, and use of a well-controlled and graded bite is evident.

13-15 Months
*Many of the skills seen at 13 to 15 months are refinements of patterns first seen at the 10 to 12 month level. 
*Controlled bite
*Able to suck through a straw without difficulty
*Long suck-swallow-breathe sequence (once ounce of liquid per sequence)
*A cough is now used to clear the airway!!
*More jaw stability and the jaw no longer moves in an up-and-down pattern
*Lower lip draws inward when the child eats from a spoon 

*Core Points to Take Away:  Suck-swallow-breath pattern is coordinated during long drinking sequences, cleaning movements integrated with chewing, refining swallowing skills present at 10-12 months, and can learn how to suck through a straw.

16-18 Months
*Movements of the jaw, lips, tongue and cheek are more finely graded.
*Sucking is combined with well-graded vertical and diagonal jaw movements to manage bolus
*Begins to move bolus across midline of the mouth though transfer is not smooth.
*Tongue tip elevates for swallow
*Children at this age may also use the tongue, teeth, or fingers to remove food from their lips.
*Rims of cups are used for more stability.

*Core Points to Take Away: Movements are smoother, minimal loss of food during chewing, and uses the rim of cups for stability. 

19-24 Months
*Children easily transfer the bolus across midline.
*Good internal jaw stability has developed (the child should no longer lose liquid when drinking from a cup).
*Lips and cheeks are used to keep a large bolus under control.
*Most children this age use their tongue to clean their lips.
*Controlled moments are used to clean the spoon - even at a faster feeding pace.
*No liquid loss with improved cup skills.
*Jaw muscles are strong enough for well controlled graded movement.

*Core Points to Take Away: the tongue can clean the lips, the bolus can be transferred across midline, there is excellent coordination of swallowing with breathing pattern, able to drink from a straw, and loss of liquid when drinking from a cup is rare. 

25-36 Months
*Facial expression indicates sensory awareness to taste and texture.
*Chewing control is improved with lips closed - bolus can now be transferred from side to side with the lips closed.
*Control is shown with an adult-sized spoon
*Cleaning movements are continuous.
*Protective cough is used to clear foreign material from the airway.
*Various textures of food are easily accepted in the mouth.
*Tongue is used to clear the area between the gums and cheeks. 
*Children this age have developed rhythmicity, stability, and separation of movement.

*Core Points to Take Away: Uses tongue to clean the area between gums and cheeks, able to grade jaw opening for different thickness of food. 

I found this youtube video that takes a very very condensed view of the above but still informative!

This website was also very helpful on some introductory knowledge into pediatric feeding and swallowing. I know that our pediatric feeding and swallowing specialist at work refers often to Beckman!

What is your experience with pediatric feeding and swallowing? Recommendations on normal to atypical education courses?


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